Diabetics are more prone to gum disease.
Left untreated, gum disease makes it harder for diabetics to control their blood sugar. Diabetics who have their gum disease treated can improve their blood sugar control thus making diabetic complications less likely.

You are a Diabetic

There is a family history of Diabetes

Frequent urination (warning sign of diabetes)

Excessive thirst/hunger (warning sign of diabetes)

Weakness/fatigue (warning sign of diabetes)

Slow healing of cuts (warning sign of diabetes)

Unexpected weight loss (warning sign of diabetes)

None of the above

How is your Diabetes control?*

Good

Fair

Poor

Date of last HbA1c and Score?

Who is your Diabetes doctor ?

Have you ever been diagnosed with Rheumatoid Arthritis?*

If you have Rheumatoid Arthritis, emerging research suggests that eliminating any gum disease and then keeping it at bay can lessen the crippling effects of Arthritis.

Yes

No

Alzheimer’s Disease*

If you have Rheumatoid Arthritis, emerging research suggests that eliminating any gum disease and then keeping it at bay can lessen the crippling effects of Arthritis.

Do you currently have Alzheimer’s Disease or Dementia

Any family history of Alzheimer’s Disease or Dementia

None of the above

Females. Check all that Apply*

Pregnant

Nursing

Taking Birth Control Pills

Are you post Menopausal?

Do you have Osteoporosis?

Family history of Osteoporosis (Risk factor)

Early menopause (Risk factor)

Rheumatoid Arthritis (Risk factor)

Inadequate exercise (Risk factor)

None of the above

Have You Ever Taken the Following Medications?*

Fosamax, Fosamax Plus D, Actonel, Boniva, Didronel, Skelid, Aredia, Bonefors, or Zometa for Osteoporosis or for any other reason?